Homestead_Nelson (2) ..r CLAIM FOR HOMESTEAD PROPERTY TAX YEAR
' _ jSTANDARD/SUPPLEMENTAL DEDUCTION FORM �YE
y State Form 5473(R18/1-20) HC10 2402%�,�. Prescribed by the Department of Local Government Finance ----- - _-_---
I' INSTRUCTIONS:See reverse side for filing instructions.
NOTE:Telephone,Social Security,driver's license,state identification and federal identification numbers are confidential under IC 6-1.1-12-37.
CERTIFICATION STATEMENT
I(We) Ilk Oh Ot\ certify that I(we)occupied as my(our)principal
place of residence or am(are)buying the f lowing described real prop t4 ytldgr fpgtracl for which a Homestead Property Tax Standard
Deduction is hereby claimed on the date this application is signed, ``IJ��C,� L�_ (date of signature). I(We):
Xfd�Own. ❑ Am(are)buying under recorded contract.
�❑ m (are)entitled to occupy as a tenant-stockholder of a cooperative housing corporation.
❑ Have a beneficial interest in the trust or the right to occupy the property under the terms of a qualified personal residence trust.
❑ Am (are)the shareholder,partner,or member of the entity that owns the property.
CLAIMANT'S INFORMATION
Name of claimant(legal name) Telephone number of claimant
is 12) 61-4-- SU3-
Social Security number of (last five digits) Driver's liven /Identification I Other number of claimant(last five digits) Issuing State
4*l t S (A„„„_„,..:„ fgpplicant dgpy,(wt have a social security number)
Name of claimant's spouse(legal name) 5�S 6�OV y�/J�ir/
Social Security number of claimant's spouse(last five digits) Driver's license/Identification/Other number of claimant's spouse(last five digits) Issuing State
(Applicable only if applicant's spouse does not have a social secunty number)
CONTRACT RECORDED
If buying on contract.Fee Simple owners name
Recorder's Once where contract is recorded Record number Page
PROPERTY DESCRIPTION
County Township Taxing district(city town.township)
Parcel number ' O O Legal description • !Is e roperty in question.
Real property ❑ Annually assessed mobile home(IC 6-I.1-7)
If any portion of the residential structure or the land not exceeding one(1)acre that immediately surro ds t t structure is used to produce income,describe the use and portion
of the properly utilized to produce income
2 G--l 4 -k -- tc ( --0 0 0 , 2-_00-- Q O
PROPERTY OWNED ELSEWHERE BY CLAIMANT
State,County.and Township Is claimant vac a homestead?
❑ Yes rI,INo
Signature of claimant
I hereby certify the above statements are true,correct,and complete. rA
AddrSss of contact(number and stir Cl.c' state,tool IP Cptla)d^ �ciAddress of vacated homestead.if any(number and street,city.state.and ZIP code)
/`^/J-`�j`O ASSESSOR USE ONLY 1WYA\ /�t(A•SSESSED VALUE ^'hI66 HOMESTEAD VALUE NON-RESIDENTIAL
VALUE
I
Landnotexceedingone(1)acreimmediatelysurrounding residential Improvements (1)•
4Other land (2) , Y,-1-)zy$y..l. ar-?
Total land(line 1 plus line 2) (3) .1 Residential improvements or F Dwelling (4). _ w __rk
annually assessed mobile/
Imanufactured home Garage (5)
{ Other improvements (6) M? R
Total Improvements(line 4 through line 6) (7) -
Total value (line 3 plus line 7) al) -
I hereb eertif the above is true,correct, Signature of Assessor/ r""�r`^'�' NTY AUDITOR Date signed(month.day.year)
and completer GIBBON COUNTY Verifying action-Signature of Auditor Date signed(month,day.year)
STANDARD DEDUCTION ALLOWANCE
20 pay 20 Lesser of 60%of the assessed value of the homestead or$45,000.
Notwithstanding any other provision,the sum of the deductions provided in IC 6-1.1-12 to a mobile home $
that is not assessed as real property or to a manufactured home that is not assessed as real property may
) not exceed one-half(1/2)of the assessed value of the mobile home or manufactured home.
1 Signatc Auditor yan ,(wrprytr�r)t
}
ure fAO for _ I Date year) ^ ,2
C
i DISTRIBUTION: Original-County Au itor.File-Sta d Copy-Taxpayer
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